EM Coding Alert

Using a sample agreement like this can ensure you get proper payment.

If you are one of the many practices that sees nursing facility (NF) patients in the office, you need to understand consolidated billing rules. As part of consolidated billing, you will likely need to bill a portion of the encounter to the payer and another portion to the nursing facility. But if you don’t have a set contract with the nursing facility, you risk not getting paid for your providers’ service.

“If a physician is on staff at the nursing home, the services are included in the consolidated billing submitted by the nursing home. However, if the physician is seeing a patient at a nursing home, that service could be billed on its own to the payer,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal at ACE Med in Pittsburgh, Pa. “It’s important to understand the differences and determine if a contractual arrangement exists between your practice and the nursing facility.”

If the physician is on staff or offering services that would be included in the consolidated billing, then you would submit a claim to the nursing facility. If the nursing facility paid your physician a set fee, then no claim would be submitted, Hauptman adds.

Reduce payment delays and claim frustration by developing a contract such as this one if your provider regularly sees the patients at the nursing facility. This way payment would come from the facility directly and they will get reimbursed through their consolidated billing.

Keep in mind: There are additional details you’ll want to add to this basic sample contract to make it specific for your practice’s needs, and you should have a competent healthcare attorney with Stark knowledge review the contract.

Additional info: See E/M Coding Alert Vol. 2, No. 9 for an in-depth article on consolidated billing rules.

SAMPLE CONTRACT

Date:

This letter serves to document an agreement between me, John Doe, MD, and XYZ Skilled Nursing Facility.

At your request, I may provide medically appropriate services to patients from your facility who are classified by the Medicare program as under skilled nursing facility care. Following evaluation and treatment, my office will send an invoice directly to your facility for reimbursement of the medical care services I have provided, at your request, to these patients.

Payment will be expected regardless of your facility’s reimbursement status with Medicare.

Payment should be mailed directly to the address below within 10 days following receipt of my invoice.

Provider tax ID number:

Please send payment to:
Billing Office Address
City, State, ZIP code

Signatures by both parties below acknowledge and consent to the above agreement.

Signature of Physician and Date _____________________

Signature of SNF and Date_____________________.